Understanding Medicaid and Medicare
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Questions and Answers

What is Medicaid?

  • A program that covers all Americans
  • A state and federal health care program for the poor (correct)
  • A program only for elderly people
  • A state and federal program for healthcare for the rich

    • What is the main difference between Medicaid and Medicare?

    Medicaid is for low-income individuals and families, while Medicare is for the elderly and certain disabled individuals.

    Who in the family uses Medicaid?

    Miss Jackson has sporadically been eligible for Medicaid.

    Why didn't Robert get treatment for his kidney condition before it became life threatening?

    <p>He lacked health insurance and did not qualify for government-sponsored insurance.</p> Signup and view all the answers

    How is Robert's dialysis paid for?

    <p>Medicare covers 80% of dialysis costs; the remaining 20% may come from Medicaid or private insurance.</p> Signup and view all the answers

    Why is Highland Park's dialysis unit more posh than the one Robert uses?

    <p>Patients at Highland Park are primarily covered by private insurers, allowing for better amenities.</p> Signup and view all the answers

    What are 'DRGs' and how do they affect the care given to Mrs. Jackson?

    <p>DRGs are diagnosis-related groups that set predetermined hospital payment rates, which leads to quicker patient discharges.</p> Signup and view all the answers

    What kinds of medical care aren't paid by Medicare?

    <p>Medicare does not cover many necessary items like medications, adult diapers, and transportation.</p> Signup and view all the answers

    What is a 'Medicaid spend-down'?

    <p>It is like a deductible, a set amount that must be spent on medical needs before Medicaid coverage begins.</p> Signup and view all the answers

    How does coverage vary between standard Social Security and SSI?

    <p>SSI is for individuals who are aged, blind, or disabled and typically provides more assistance than standard Social Security.</p> Signup and view all the answers

    Why do some blacks distrust white doctors?

    <p>Many blacks perceive doctors as aloof and confusing, and there are concerns about their treatment and possible involvement in dangerous human experiments.</p> Signup and view all the answers

    What might cause the longer wait times for black patients in organ transplants?

    <p>Longer wait times may be due to biological differences, lower organ donation rates among blacks, and systemic discrimination in organ matching systems.</p> Signup and view all the answers

    Why was so much spent on Mrs. Jackson's healthcare in the last three months of her life compared to previous years?

    <p>Mrs. Jackson received extensive medical interventions for her worsening conditions, resulting in high costs, despite having struggled to access care earlier in her life.</p> Signup and view all the answers

    How does the American healthcare system compare to those in Canada and Great Britain?

    <p>Unlike the U.S., Canada and Great Britain provide healthcare to all citizens at lower costs and often with better health outcomes.</p> Signup and view all the answers

    What changes in Medicaid might affect children like Brianna?

    <p>Changes include Medicaid eligibility for children and pregnant women whose family incomes are below certain poverty thresholds.</p> Signup and view all the answers

    What reforms to the American healthcare system does the author recommend?

    <p>The author recommends guaranteeing a basic level of healthcare for all, reforming Medicaid to improve accessibility, and emphasizing caring over curing in the healthcare system.</p> Signup and view all the answers

    What does the prothrombin time (PT) test measure?

    <p>Patients' coagulation levels</p> Signup and view all the answers

    What was Mrs. Jackson's PT level during her emergency room visit?

    <p>35</p> Signup and view all the answers

    Mrs. Jackson was closely monitored after her PT level registered at 35.

    <p>False</p> Signup and view all the answers

    What level of Coumadin did Dr. Gurevich want for Mrs. Jackson?

    <p>1 1/2 to 2 times the normal reading</p> Signup and view all the answers

    What could have been done to monitor Mrs. Jackson's condition better?

    <p>The home health nurse could have drawn her blood for a PT test.</p> Signup and view all the answers

    What was one reason Mrs. Jackson did not attend support groups after losing her leg?

    <p>Support groups were held in the mornings when she had physical therapy.</p> Signup and view all the answers

    Why are rehabilitation centers more profitable than hospitals?

    <p>Rehabilitation centers get paid under a different reimbursement method</p> Signup and view all the answers

    Medicare provides equal funding for inpatient and outpatient psychological care.

    <p>False</p> Signup and view all the answers

    What percentage of Medicare expenditures goes to hospitalizations?

    <p>63%</p> Signup and view all the answers

    Why do emergency rooms get used for routine care?

    <p>Long waits for appointments and lack of trust in private doctors.</p> Signup and view all the answers

    What happened to Medicare reimbursements in the 1980s?

    <p>The funding ended as payers moved to control healthcare costs.</p> Signup and view all the answers

    Why is Mt. Sinai Hospital in bad financial shape?

    <p>It has fewer private insurance patients and high levels of uninsured patients.</p> Signup and view all the answers

    What are the two primary tracks to provide income and medical care to elderly and disabled people?

    <p>Medicaid and Supplemental Security Income</p> Signup and view all the answers

    Mrs. Jackson received Supplemental Security Income payments.

    <p>False</p> Signup and view all the answers

    What is the medically needy level in Illinois in 1989?

    <p>292</p> Signup and view all the answers

    How much did Mrs. Jackson receive from Social Security each month?

    <p>686</p> Signup and view all the answers

    Why did Mrs. Jackson need Medicaid despite receiving Social Security?

    <p>To cover medications and additional needs.</p> Signup and view all the answers

    What was the consequence of the patchwork system of healthcare coverage in the United States?

    <p>Inconsistencies and high administrative costs</p> Signup and view all the answers

    Why was it important for Mrs. Jackson to be considered 'disabled'?

    <p>To qualify for disability payments and medical insurance.</p> Signup and view all the answers

    What was the cost of a month's worth of medication for Mrs. Jackson?

    <p>75</p> Signup and view all the answers

    Medicaid covered all of Mrs. Jackson’s medication needs.

    <p>False</p> Signup and view all the answers

    What was the largest expansion of Medicare since 1965?

    <p>Medicare Part D</p> Signup and view all the answers

    Why did Mrs. Jackson sometimes miss appointments with her primary physician?

    <p>Affordability of transportation.</p> Signup and view all the answers

    Mrs. Jackson received consistent care from the same healthcare providers.

    <p>False</p> Signup and view all the answers

    Why did Mrs. Jackson get Coumadin poisoning?

    <p>Lack of medical supervision and oversight.</p> Signup and view all the answers

    What is a consequence of the lack of continuity in care for poor minorities?

    <p>Inadequate treatment and increased complications.</p> Signup and view all the answers

    What is demarketing?

    <p>Demarketing was an unconventional tactic denied by Mount Sinai in the mid-1980s when it formally reaffirmed to serve the disadvantaged.</p> Signup and view all the answers

    Who is responsible for Tommy Markham's health?

    <p>Tommy Markham is responsible for his own health, although various factors, including denial and the healthcare system, complicate this.</p> Signup and view all the answers

    Why was Mrs. Jackson's home care so limited?

    <p>Mrs. Jackson's home care was limited due to increased Medicare denial of home health claims.</p> Signup and view all the answers

    Why do many poor African-Americans have trouble getting into a nursing home?

    <p>Many poor African-Americans have trouble getting into nursing homes due to being primarily poor Medicaid recipients.</p> Signup and view all the answers

    Why didn't Jackie sign up to be paid for caring for her mother?

    <p>Jackie didn't sign up because she worried about losing her welfare grant, which would impact her children's Medicaid.</p> Signup and view all the answers

    Why didn't Brianna get her measles vaccination?

    <p>Brianna did not get her measles vaccination because Jackie skipped the appointment, not thinking about the consequences.</p> Signup and view all the answers

    What is considered 'the original sin of American health policy'?

    <p>The original sin of American health policy is Congress's decision to link Medicaid to welfare and Medicare to Social Security.</p> Signup and view all the answers

    Why isn't most Medicaid money spent on poor children?

    <p>Most Medicaid money isn't spent on poor children because the elderly and disabled account for a large share of expenditures.</p> Signup and view all the answers

    Why does being poor affect your chances of getting a transplant?

    <p>Being poor affects transplant chances due to limited access to high-quality primary care and referral networks.</p> Signup and view all the answers

    Why did whites in Illinois receive transplants at higher rates than blacks?

    <p>Whites in Illinois received transplants at higher rates than blacks due to both economic and genetic factors.</p> Signup and view all the answers

    Study Notes

    Medicaid vs. Medicare

    • Medicaid serves low-income individuals, but fails to cover over half of the poor due to stringent income restrictions.
    • Working poor often lack Medicaid assistance and may remain uninsured, although some children are gradually added through reforms.
    • Despite Medicaid's intention to provide care, patients experience delays and challenges in finding decent doctors, as physician reimbursements are significantly lower than commercial rates.
    • Medicare covers most Americans over 65, along with certain disabled individuals; it cannot arbitrarily cut patients from its rolls.
    • While Medicare generally offers better access to care compared to Medicaid, gaps exist, such as lack of coverage for medications and transportation.

    Family Impact on Coverage

    • Cora Jackson, Jackie's grandmother, relied on Medicare and was sporadically eligible for Medicaid; her Medicaid status depended on her medical expenses reaching a certain threshold.
    • Jackie faced challenges accessing care; her family had no private insurance, exemplifying the struggle of many low-income families.

    Robert's Treatment Delays

    • Robert’s renal failure stemmed from undiagnosed focal glomerulosclerosis; he lacked insurance from short-term jobs and didn't qualify for government assistance.
    • Economic constraints and potential lack of awareness about his illness's severity delayed his medical care until it became critical.

    Dialysis Coverage

    • Dialysis is predominantly provided by for-profit organizations, raising concerns about cost and quality of care.
    • Medicare covers 80% of dialysis costs due to special provisions for end-stage renal disease, but patients still have to find additional funds for the remaining costs.
    • Many dialysis patients are below the poverty line, indicating a significant overlap between chronic illness and economic hardship.

    Disparities in Care Facilities

    • Wealthier dialysis units, like those in Highland Park, offer superior amenities compared to units like Neomedica, reflecting disparities in service quality based on patients' ability to pay.
    • Social workers in affluent areas have smaller caseloads, allowing for more personalized attention, a stark contrast to the crunch experienced by those serving lower-income patients.

    DRGs and Home Healthcare

    • Diagnosis-Related Groups (DRGs) introduced in the 1980s incentivized quick patient discharge, resulting in increased reliance on home health services for many families.
    • Although home health expenditures grew, they remain a small percentage of overall Medicare spending, showcasing ongoing challenges in prioritizing home-based care.

    Medicare Coverage Gaps

    • Medicare pays for essential services but excludes many necessary items, including adult diapers and transportation.
    • Even eligible seniors may struggle to access supplemental programs due to administrative barriers and complex application processes.

    Understanding "Medicaid Spend-Down"

    • Medicaid spend-down functions like a deductible, requiring individuals to incur certain medical expenses before coverage begins, complicating access to care.
    • Many eligible individuals may not regularly maintain spend-downs due to bureaucratic challenges and lack of support in managing their healthcare finances.

    SSI vs. Social Security

    • SSI provides support to individuals who have worked little or in jobs without Social Security contributions, resulting in lower income but automatic Medicaid coverage.
    • Dual track of income support highlights flaws, as Social Security recipients often fall into gaps requiring additional assistance like Medicaid.

    Consequences of a Patchwork System

    • The United States' fragmented healthcare approach leads to inconsistencies and high administrative costs, disadvantaging many citizens who lack basic healthcare coverage.
    • Administrative overhead consumes a significant portion of healthcare spending, contrasting sharply with countries like Canada that maintain more integrated systems.### Healthcare Access and Inequalities
    • Medicare guarantees healthcare for all citizens, reducing unnecessary spending on patient eligibility.
    • Mrs. Jackson's illegal activities stemmed from her need for financial support after her boyfriend's death and her reliance on disability benefits.
    • She collected $200/month in Social Security disability benefits due to high blood pressure and arthritis.
    • Working under an assumed identity, she avoided jeopardizing her disability income while earn an additional $500/month, keeping her income around the poverty level.
    • Disability payments are cut off if earnings exceed $300/month, incentivizing illegal work for additional income.

    Medicare Prescription Drug Coverage

    • Medicare Part D was introduced to assist seniors in purchasing medications, costing $400 billion to implement.
    • Benefits began in 2006, allowing seniors to buy discount cards and import cheaper drugs from Canada.
    • Medicare recipients would pay a monthly premium and deductible while enjoying coverage for 75% of drug costs up to a specified limit.
    • Prior to this expansion, Mrs. Jackson struggled with medication costs, spending $75/month for chronic conditions.
    • Medicaid’s coverage was unreliable for Mrs. Jackson, creating financial strain, illustrating how the system often leaves beneficiaries vulnerable.

    Barriers to Medical Appointments

    • Transportation costs were a significant barrier, preventing Mrs. Jackson from attending necessary doctor appointments.
    • Scheduling gaps created logistical challenges in managing consecutive appointments with multiple specialists.
    • Medicare doesn't cover transport costs unless deemed medically necessary, exacerbating access issues for low-income patients.

    Health Disparities Among Minorities

    • Poor care quality for minorities and the poor often stems from systemic issues, including lack of continuity in care.
    • Mrs. Jackson faced severed healthcare provider relationships, making holistic management of her diabetes difficult.
    • Emergency and outpatient services were frequently used by low-income individuals, resulting in episodic care instead of consistent treatment.

    Coumadin Poisoning Incident

    • Mrs. Jackson experienced Coumadin poisoning due to a lack of communication between healthcare providers, resulting in dangerously high blood levels.
    • Emergency room staff failed to monitor Mrs. Jackson’s coagulation levels accurately, leading to significant health risks.
    • After missing multiple appointments, Mrs. Jackson continued taking her medication without proper oversight, worsening her condition.

    Hypothetical Scenario: Mrs. Jackson as an Upper-Class Retiree

    • An upper-class retiree may have encountered better healthcare continuity, higher quality of care, and access to resources preventing medical crises.
    • Improved communication among healthcare providers would likely lead to proactive management of health conditions and fewer emergency interventions.### Diabetes and Socioeconomic Factors
    • Diabetes prevalence is higher in low-income, less educated groups, but controlling for obesity and age minimizes socioeconomic impact.
    • Black individuals face more severe diabetes complications: twice the amputation rate and three times the kidney failure compared to whites.
    • Hospital admission for diabetes as a cause is more frequent in poor areas; significant disparities persist despite Medicare's coverage.
    • Limited access to medications for underinsured diabetics complicates disease management.

    Healthcare and Financial Incentives

    • Rehabilitation centers like Schwab are more profitable than hospitals due to payment structures set by Medicare; hospitals are incentivized to discharge patients quickly.
    • Medicare’s Diagnosis-Related Group (DRG) system provides fixed reimbursement for hospital stays, pushing hospitals to manage patient turnover.

    Mental Health Care Disparities

    • After losing her leg, Mrs. Jackson's depression went untreated; rehab facilities prioritize physical therapy over psychological support.
    • Medicare offers better reimbursement for inpatient mental health care versus outpatient care, creating bias against outpatient services.
    • Public insurers like Medicaid do not cover outpatient mental health services, limiting access for lower-income patients.

    Emergency Room Utilization

    • The emergency room serves as a primary care option for the urban poor due to a lack of accessible physician appointments.
    • A significant percentage of Medicaid recipients use emergency services for non-urgent conditions, highlighting systemic healthcare gaps.
    • Factors driving this utilization include distrust of local providers and a long history of emergency room reliance.

    Funding and Financial Struggles of Hospitals

    • Public hospitals like Mount Sinai face financial hardships due to legislative reimbursement policies favoring more affluent institutions.
    • Mount Sinai historically has a higher proportion of Medicaid patients, leading to financial strain compared to hospitals with higher privately insured patient counts.
    • The hospital has survived through community-oriented initiatives and adapting its services to the local population's needs.

    Mount Sinai's Strategic Shifts

    • Mount Sinai shifted from trying to attract privately insured patients to focusing on public-private partnerships and community service.
    • Clinics were established in underserved neighborhoods to improve access and secure additional federal funding.
    • The hospital relied heavily on corporate and foundation grants for operational support due to a lack of robust philanthropic backing from the Jewish community.

    Demarketing Strategy

    • Demarketing at Mount Sinai aimed to discourage non-target patients while reaffirming its commitment to serve low-income, uninsured communities.
    • This strategic focus influenced the hospital's service delivery approach and resource allocation.

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    Description

    Dive into the nuances of Medicaid and Medicare with this quiz. Explore key differences, eligibility, and real-life implications through the case of Robert and his dialysis treatment. Test your knowledge on healthcare programs and their impact on families.

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